Co-design of a Mobile Stroke Unit pathway highlights uncertainties and trade-offs for viable system-wide implementation in the English and Welsh NHS

Abstract

Background: Mobile stroke units (MSUs) are specialist ambulances equipped with scanning and point of care testing that can identify patients eligible for intravenous thrombolysis - medication to dissolve a clot used in ischaemic strokes - and provide this on location. While benefits of MSUs have been demonstrated, this is context dependent. Routine use of MSUs across the English and Welsh National Health Service (NHS) has not yet been considered, and as such no pathway for their operation exists. This study aimed to co-design a viable pathway, detailing dispatch, staffing and treatment decisions, for MSUs within the NHS context.

Methods: The study used interdisciplinary co-design alongside Nominal Group Technique (NGT) to generate consensus. Participants were recruited using a combination of purposive, opportunistic and snowball sampling. Data collection took place in online workshops, across three rounds, with supplemental interviews conducted where required. Data were analysed as an ongoing process, with participants checking interpretations after each round, and then further analysed deductively to identify key uncertainties following all the rounds. Consensus threshold for the NGT was set a priori at ≥ 80%.

Results: An MSU pathway that reached consensus for being viable within the NHS was developed with consideration for current systems and pressures. Key uncertainties were identified such as where to base the MSU. We also identified where participants had to make trade-offs in the co-designed pathway, such as staffing considerations. Together, the uncertainties and trade-offs represent challenges to MSU implementation and are presented alongside the process to reach the finalised pathway. Future developments which may have implications for the implementation of MSUs were also explored.

Conclusions: The co-designed MSU pathway provides a foundation for MSU implementation in the English and Welsh NHS and can be subjected to local and regional modifications required for implementation. However, optimal implementation is likely hindered by several uncertainties and trade-offs, including the geographical base of the MSU and staffing, that represent challenges to implementation of MSUs at scale. Future developments in acute stroke care may help to mitigate these challenges, such as developments in artificial intelligence to read scans and improved access to telemedicine.

Clinical trial number: Not applicable.

Keywords: Co-production; Emergency medicine; Mobile stroke unit; Nominal group technique; Pathway development; Pre-hospital care; Stroke.

Fig. 1

Existing pre-hospital acute stroke pathway

Fig. 2

Finalised MSU pathway. * MSU would be staffed by an experienced stroke nurse, paramedic, radiographer and an additional member of ambulance service staff. This was a trade-off as participants preferred a stroke physician but recognised that the shortage of stroke physicians would not make this viable. † Dual dispatch has been included in the pathway however some participants raised concerns about the viability and justification of this given current resource constraints. Without dual dispatch it was recognised that the MSU could spend a significant amount of time treating non-stroke related patients. †† Local decision making would be required about the criteria for paramedics to contact the MSU. ¶ These elements are contingent on dual dispatch being implemented. Alternatively, if the MSU attended as a single resource to a none-stroke patient then local decision making would be required about whether a standard ambulance should be dispatched so the MSU could be ‘stood down’. § Telemedicine was a trade-off in relation to physician shortage concerns. Participants recognised that telemedicine would not always be reliable in certain geographical areas and local decision making would be required about whether there was an area within an acceptable distance that would have connection or whether they should revert to standard care